Basic Information
| Provider Information | |||||||||
| NPI: | 1346265808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADESIDA | ||||||||
| FirstName: | OLUREMI | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 11115 PARKVIEW PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739965 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01068108A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036-116960 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 01068108A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 036-116960 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000655415 | 01 | IN | ANTHEM | OTHER | 200979870 | 05 | IN | MEDICAID | 8466700 | 05 | NJ | MEDICAID | 001289011 | 05 | PA | MEDICAID |